Beyond the financial ROI: Expert thoughts on EHR selection

Although top-tier EHR vendors Epic and Cerner steal headlines, the upper rank of their competitors have demonstrated immense resiliency and churn out good-looking numbers with promise for growth. But when it comes to selecting an EHR, providers must consider questions about interoperability, information sharing, cloud access and accountability, and all EHR vendors do not offer the right answers for everyone.

Big-name EHR vendors, the EHR selection process and how CIOs operate in an evolving health IT market were among topics an expert panel tackled at the Becker's Hospital Review 4th Annual CEO + CFO/CIO Roundtable in Chicago.

Panelists included Bill McConnell, senior vice president and CIO for Indiana University Health in Bloomington; David Chou, global digital healthcare advisor and former CIO for University of Mississippi Medical Center in Jackson; and Stephen Kahane, MD, executive vice president and president of client organization for athenahealth. The panel was moderated by Scott Becker, publisher of Becker's Hospital Review.

Reducing integration points

"Epic, McKesson, Cerner, Meditech — I've used them all," Mr. Chou said. "I think the future of healthcare from a CIO perspective is trying to cut down integration points." According to Mr. Chou, the drive for fewer integration points between IT systems is one big factor behind the widespread adoption of consolidated models of EHR systems. System connectivity within organizations has historically been a big challenge, and a consolidated model eliminates the worry of data transfer and navigation between the financial, clinical and all other aspects of IT within a network.

CIOs' focus on fewer integration points dovetails with connecting to cloud-based systems to empower physicians, which Dr. Kahane said is one way to reduce IT touch points.

"The most important core competence of winning health systems of the future is to establish and support a high-performing medical group," Dr. Kahane said. "We talk a lot about the hospital information system, but to be honest, I don't get it. Most care is delivered outside of that venue. Over half of the revenue in most health systems originates from affiliated, non-employed physicians."

Dr. Kahane argues a cloud-based vendor enables the majority of providers in a health system — urgent care centers, post-acute care centers, clinics and affiliated physician groups — to securely access patient data across a continuum of care without the need for a plethora of integration points. Mr. Chou says it's this variety of integration points that makes consolidating to one big, pervasive EHR a tempting move for big systems, particularly when they are merging and acquiring other providers and facilities.

The interoperability factor

But as those large systems opt for Epic or Cerner, they lose the cloud–based component, and decrease crucial visibility of the care continuum, Dr. Kahane points out. In these instances, looking at interoperability capabilities is key, according to Mr. McConnell, who recently oversaw IU Health's consolidation to Cerner's EHR platform across all of its facilities. IU Health has 2,000 employed physicians, about 6,000 other credentialed physicians who are practicing independently of the system. In order to remain patient centric in such a large environment, it's important for care team members to have visibility on all things going on with patients, he said.

"You've got to be able to have interoperability for medical care to be delivered effectively across the continuum of care," Mr. McConnell said. "There's never going to be one EMR that will support all points in that continuum so you've got to look at interoperability capability."

Dr. Kahane of athenahealth said KLAS' recent report on vendor interoperability focused more on outcomes and performance indicators as they relate to IT, rather than merely comparing features between vendors and systems as it did in previous years. This may be an indicator of the growing expectation for IT systems to demonstrate more meaningful functionality.

As health systems take on more financial risk for improved care, Mr. Chou said buy-in from the executive team as is necessary. "It's no longer an IT decision," he said. "Looking at how you integrate with other hospitals, with community physicians, affiliates or facilities you may want to acquire all come into play during system selection. The EMR is a tool to run your operation, but not the end-all be-all solution itself."

According to Dr. Kahane, that's precisely why vendors need to step up and demonstrate not only a financial return on investment, but an ROI for meaningful use, physician satisfaction and patient care. As it stands now, large health systems may be opting for bigger name vendors out of fear they won't be able to compete using a less prominent EHR. This could change over time as CIOs and hospitals demand more functionality from their EHR systems. In this case, smaller vendors may be more flexible and willing to adjust their platforms, giving them the upper hand. Mr. McConnell said over time if large vendors want to offer their customers the features they ask for, it may impact their market shares. Building more functionality and interoperability in EHRs will put less pressure on providers to side with one vendor or another, decreasing the likelihood of industry monopolies.

Meaningful ROI

"As interoperability increases in its capabilities, the big players will have to get better at supporting it, which opens up the opportunity for niche players to come in," Mr. McConnell said. "I started my career when IBM ruled the computing world, but because they were proprietary and didn't have open architecture, their competitors developed open architecture. IBM has struggled to regain its status at the top of the mountain since then, and I think the same type of scenario will play out with EHRs in healthcare."

This is an area where some of the more modest but still competitive vendors can get a leg up, Dr. Kahane said. At athenahealth, where he oversees client organization, he said more than 100 companies are currently developing applications built on the vendor's open architecture.

"Those apps and companies compete directly with our own innovations," Dr. Kahane said. "It can impact our revenue, it can compromise us, but it keeps everyone on their toes and I think it's the right thing to do for healthcare."

Panelists agreed: Keeping innovation in mind across health systems and a focus that goes beyond strictly financial ROI is part of the changing healthcare landscape. All health systems are now software companies, Mr. Chou said.

"Every time I go to a board meeting and I'm asked, 'How can you justify the ROI on this EHR investment?' I ask back, 'How do you justify electricity? What is the ROI on that?'" Mr. Chou said. "That's just how you have to look at it."

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